Heather J. Clawson and Nicole Dutch
Part of a larger project:
Study of HHS Programs Serving Human Trafficking Victims
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health & Human Services
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This is the fourth in a series of Issue Briefs produced under a contract with the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE), to conduct a study of HHS programs serving human trafficking victims. Funded in the fall of 2006, the purpose of this exploratory project is to develop information on how HHS programs are currently addressing the needs of victims of human trafficking, including domestic victims, with a priority focus on domestic youth. This project also consists of reviewing relevant literature, and identifying barriers and promising practices for addressing the needs of victims of human trafficking, with a goal of informing current and future program design and improving services to this extremely vulnerable population.
This issue brief focuses on the importance of case management in working with international victims of human trafficking from the point of identication until a victim reaches self-sufficiency. This brief looks at the characteristics of an effective case manager along with the benefits not only to victims but also to other key stakeholders, including law enforcement and service providers. This brief also examines the challenges to effective case management and the implications for victim recovery.
While much of the information presented in this issue brief may also apply to the case management of U.S. citizen and legal permanent resident (or "domestic") trafficking victims, the focus is more directly on international victims due to the restrictions of available federal funding to this population.
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The Trafficking Victims Protection Act of 2000 (TVPA) recognized the importance of providing benefits and services to victims of human trafficking. Initially, emphasis was placed on the needs of international victims who were largely understood to be either undocumented or in possession of marginal legal documentation related to their presence in the U.S., thus making these individuals generally ineligible for most major benefit programs. Specifically, Congress wanted to ensure that trafficking victims were treated humanely and had access to assistance. To this end, international victims were to be treated the same as refugees for benefit eligibility purposes. That is, international adult victims of human trafficking who receive an HHS letter of certification are eligible to apply for benefits and services under Federal or state funded programs, to the same extent as refugees. Services include refugee cash, medical assistance, and other social services. International minor victims do not need to be certified but instead receive a letter of eligibility from HHS and are then eligible to apply for a similar range of services, including the Unaccompanied Refugee Minor program.
Subsequent reauthorizations of the TVPA recognized domestic trafficking victims and their needs for service, in particular residential facilities for domestic youth. No resources have been appropriated to implement or provide services to domestic victims. Instead, the legislative assumption seems to have been that domestic victims would have better access to various mainstream programs (e.g., child protective services, foster care, runaway and homeless youth programs, Medicaid, etc.) by nature of their citizenship or legal permanent residence. While the process for becoming eligible for and accessing benefits and services may be laid out in the legislation or guidances of agencies, it is not well-known or understood by victims of human trafficking, whether international or domestic. So how do victims navigate through this process? How do they learn about their rights as victims? How do they obtain the necessary documentation and complete the required forms in order to access the services that they need? This is where the role of the case manager becomes critical throughout the duration of a case, whether the victim is male or female, an adult or child, or international or domestic.
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The National Association of Case Management (2008) defines case management as "a professional practice in which the service recipient is a partner, to the greatest extent possible, in assessing needs, defining desired outcomes, obtaining services, treatments, and supports, and in preventing and managing crisis." This collaborative process is intended to promote quality of care and cost-effective outcomes that enhance the physical, psychological, and vocational health of the participant. At the center of this process are the case manager and the client.
|"We're [Case Managers] the ones that act as the hub and refer to others
and help them get settled; and help them work with law enforcement while
their case is being investigated."
While many agencies provide case management as part of their menu of services for trafficking victims, having a central case manger is viewed by service providers and law enforcement representatives as a critical service not only for the victim but also for other service providers and agencies involved in a trafficking case. Victims of human trafficking often interact with multiple systems and their representatives, such as law enforcement, prosecutors, immigration attorneys, medical providers, mental health professionals, shelter/housing providers, child care providers, public benefits personnel, employers, and landlords. This can be overwhelming for victims, especially international and minor domestic victims who are unfamiliar with U.S. systems and are dealing with the trauma of their trafficking experience.
|"We meet the clients where they are both emotionally and physically.
We act as their safety net, sometimes we are the only ones there for them."
"Informal support networks will grow over time but until then, these victims are isolated and in most cases, only have us [case mangers] to depend on for support."
In addition to serving as a single point of contact, a central case manager can assess a client's need for services and support; identify, obtain, and coordinate those services for the client; coordinate and manage communications across systems; and serve as a liaison for the client. Other functions of the case manager include: translating for the victim or obtaining translation services; accompanying clients to appointments; assisting/teaching clients to access public transportation; and in some cases, teaching clients basic life skills. Sometimes this includes teaching clients how to use kitchen appliances or how to make a phone call.
For many case managers the most important service provided to their clients is general support. This can be in the form of answering a call in the middle of the night from a client who has experienced a nightmare, or spending an afternoon sitting with a client to keep them company because they are afraid to leave their apartment out of fear of being identified by the trafficker. Offering reassurance and comfort to clients often occupies much of a case manager's time, but it is essential in building trust and rapport with the client. In fact, many providers and law enforcement representatives note that the case mangers are often the first and sometimes the only person a victim trusts.
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Given the multiple roles of the case manger and the comprehensiveness of the case management services required by most trafficking victims, it is not surprising that case management comes with some challenges and limitations.
Resource Limitations. One of the most common challenges reported by service providers is the limited resources available to support case management services. Those working with victims have described case management as a 24/7 responsibility. While case managers admit this is not true of all victims, it does appear to be the case when one first begins working with a victim and during critical points, such as following depositions, appearances in court, application renewals for benefits and services, and reunification. This intensive and sometimes unpredictable need for support and assistance by international victims specifically, limits the size of the case load a case manager can effectively carry. As one case manager stated, "My one trafficking victim requires more of my time than 25 of my domestic violence cases."
Some agencies find it difficult to retain qualified case managers because the compensation is low and the demands of the job are high. Many smaller agencies report struggling with the structure of some funding streams. For example, the per-capita funding available under the ORR Anti-Trafficking Services Subcontracts is based on reimbursement for services and can pose challenges for agencies without diverse funding streams or large infrastructures to support staff during "downtimes" (i.e., low client referrals). Larger agencies are able to support case managers under other funding streams and often have case managers working with different victim populations whereas some of the smaller agencies, often specific to human trafficking, have not been able to diversify their funding. This has resulted in some agencies needing to move to part-time case managers; a challenge given the 24/7 responsibility of their job with some victims.
However, those in the field recognize that the current per-capita funding is intended to be a more efficient use of limited resources than previous funding streams in that it allows for the provision of services to victims "anytime, anywhere" throughout the country, and ensures an efficient use of limited resources. But it may take time for some agencies to figure out how to work within the various reimbursement systems.
Although there are challenges, HHS has recognized some of these limitations and made resources available to fund case management services for international victims. For domestic victims, however, the lack of comprehensive case management has not yet been addressed. According to law enforcement and service providers, this remains a critical problem in need of resources to begin to solve. Domestic victims have to rely on case management services offered through what are described as already overburdened systems, such as the child welfare system and domestic violence and youth shelter programs.
Length of Service Eligibility. Although it is possible to get exceptions from funding agencies, case managers note that time limits associated with some types of services, such as the 8 months for refugee cash and medical assistance, are often not sufficient to move a client from "crisis to thriving." According to service providers, pre-certification can take more than a year and post-certification resources requiring month-to-month approval are limited in duration. There is general recognition in the field that significant time, and thus resources, are needed to build trust with clients, move them into recovery, and help them become self-sufficient. It also often takes time to convince victims to cooperate with investigations and prosecutions, and/or for law enforcement agencies and officials to determine that a trafficking crime has occurred.
Staff Burnout and Turnover. Case managers are characterized as dedicated, committed individuals who are overworked and underpaid. As a result, staff burnout and ultimately staff turnover are significant problems for many agencies. Many case managers' report experiencing secondary or vicarious trauma. Unfortunately, they also acknowledge that they have very little time to take care of themselves. Not only did this affect the case managers, but victims often experience changes in case managers as a result. Given the time needed to establish trust with the victims and the importance of the relationship between the case manager and the victim, these changes in case managers are viewed as setbacks to recovery.
|"This is a major issue. It is more than burnout and compassion fatigue,
it's worse. This type of work is hard and the staff get stressed. And what
is in place to support the staff? Nothing. We need to find ways to help staff
address secondary trauma. For example, I would like to be able to offer my
staff a day off or a small token to show how much they are appreciated."
Availability of Services. Regardless of the type of service sought, the role of the case manager in helping victims' access services is viewed as essential for both international and domestic victims. Unfortunately, accessing certain services can be a challenge in many communities. Specifically, service providers report limited availability of emergency and permanent housing (in particular for men and children), mental health services, and dental services. When services are available, there are often long waitlists or significant costs associated with the services.
Additionally, access to culturally-appropriate services, including providers who can communicate with clients in their native languages, are limited. While case managers themselves did not report problems communicating with clients, either directly through multi-lingual staff or indirectly through the use of translation services, other benefit or service agencies that clients were referred to often lacked these capabilities.
Access to Information. Another significant challenge identified by case managers is limitations to information sharing among providers and with other agencies. Specifically, issues of confidentiality are often identified as barriers to keeping clients informed about their legal case and, in some cases, medical diagnoses or results. As the liaison for the client, some case managers report finding themselves in difficult positions where the client expects them to have the information they need and when they cannot provide answers to the client, it is the case manager who is viewed as the "bad guy." This creates issues of distrust, which ultimately can cause setbacks in the client's progress toward self-sufficiency.
Despite these challenges, case management is viewed as a critical service that has benefits not only for the victim, but for other stakeholders in this fight against human trafficking.
Benefits for Victims. First and foremost, the case manager is seen as critical by service providers, law enforcement, and victims themselves as helping the victim move toward self-sufficiency. Through educating victims of their rights, helping them understand and navigate through our criminal justice, immigration, and human service systems, identifying and making appropriate referrals, assisting victims in accessing services, advocating on behalf of the victim to other providers and agencies, and providing moral and emotional support, the victim can focus on his/her recovery.
Benefits for Law Enforcement. The case manager is viewed as critical in helping stabilize the victim to assist in the investigation by providing services and support that are beyond the means and expertise of law enforcement. This results in victims who are able to share, more quickly, with the officers, information that can aid in an investigation and, in some cases, the apprehension of the trafficker. Additionally, for many in law enforcement, the case manager is viewed as a "timesaver" for the officer. That is, law enforcement officers note that having a case manager from the outset who can work with the victim frees up the officer to conduct the investigation.
Benefits for the Prosecution. According to some Federal agents, the case manager is the one constant for victims throughout the process of the investigation and prosecution. For the prosecution, this source of stability for the victim translates into a more consistent and credible witness. Some prosecutors describe trafficking cases as victim-dependent. That is, the testimony of the victim or victims is essential to the success of the case. It is not surprising, then, that case management and case managers play an important role for the prosecution.
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Agencies that work with victims of human trafficking have identified several promising approaches to case management for these victims that other agencies can adopt.
Culturally Appropriate Case Management and Services. Culturally appropriate case management services and support can include education regarding the culture and religious beliefs of potential clients to ensure their initial contact with the case manager is a positive and appropriate experience. Additionally, this preparation and education can assist a case manager with the assessment of the victim's needs (e.g., knowing how to ask for information that might be sensitive or taboo in some cultures). A case manager can also use knowledge of a client's culture and background to help identify appropriate services. As one case manager stated, "You can't tell if a service or program is culturally appropriate from the yellow pages. You need to meet with the providers, in some cases, offer them training on the issue of human trafficking, and ensure that they can offer culturally sensitive services."
Case managers acknowledge that they cannot expect a client to follow a service plan successfully if it is not developed with consideration of the client's background.
Client-Specific, Flexible Approaches. Another promising approach noted by case managers is to work with clients from where they are and move them toward self-sufficiency. Specifically, case managers indicate that it is important to be flexible and start where the client is most comfortable instead of making assumptions about the client and his/her abilities. For some case managers, a promising approach to moving clients toward self-sufficiency includes teaching clients how to do things for themselves rather than doing too much for them. While there are some clients that need more hand-holding than others (in particular during the pre-certification phase), there has to be a gradual decrease in case manager involvement to reduce dependency on the case manager and other service providers. Yet, all service providers note that the timeline toward self-sufficiency varies by client, and therefore a single approach to case management does not work with this population.
Collaborating with Others. A consensus across providers is the importance of working collaboratively with other agencies to address human trafficking adequately and effectively to meet the needs of victims. Case managers note that collaboration is essential to helping victims. This includes collaboration among case managers from different agencies who are providing services to victims, collaboration between case managers and law enforcement, and collaboration between case managers and attorneys. Through formal memoranda of understanding; information-sharing protocols; and shared policies, practices, and procedures, some agencies have begun to work effectively together while recognizing their boundaries or limitations.
Consistent, Central Case Manager. The importance of assigning a single case manager for each victim of human trafficking is shared across service providers and law enforcement. Given the difficulty of building trusting relationships with victims, the more change or turnover in case managers the more difficult it is to make progress with clients. Assigning a single case manager to each victim from the time of referral or identification until the closure of all aspects of the case (e.g., service component, immigration component, criminal prosecution component) is essential.
Additionally, having a single, central point of contact within each agency providing services for victims of human trafficking is viewed as an essential promising practice to ensuring seamless delivery and effective communication across all agencies, including law enforcement.
Self-Care for the Case Manager. Finally, an overall theme across service providers, although it is not always in place, is support for the case managers (and other service providers). The long hours, emotional commitment, and vicarious trauma experienced by many case managers needs attention. Case managers report experiencing stress, frustration, and difficulty providing the level of service and support needed by their clients. They need the time to deal with their own reactions to these cases, whether this includes an opportunity to talk to a mental health professional or just some time off. Any agency providing case management to victims of human trafficking needs to examine its policies and practices related to secondary or vicarious trauma experienced by its staff.
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Case management services are vital to a victim's road to recovery. While faced with challenges and limitations, service provider agencies and case managers have found ways to overcome these barriers through promising approaches to effective case management. Consistent, compassionate, culturally competent and dedicated case managers are offering comprehensive case management services and support to victims of human trafficking and are producing positive results for their clients and funding agencies, as well as benefiting law enforcement.
|Ingredients for Effective Case Management
Extracted from the NACM Web site, http://www.yournacm.com/definition.html
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Study of HHS Programs Serving Human Trafficking Victims, Project Page
Human Services Policy (HSP)
Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services (HHS)
Last updated: 06/26/2008